The present study contributes to fill knowledge gaps about the health and life conditions of the prison population. Especially by describing socio-epidemiological aspects of this population with emphasis on vulnerabilities related to hepatitis C.
It is known that incarceration is associated with a higher occurrence of infectious diseases, with great variation between countries in the world. However, there is a consensus that the prevalence of HCV is extremely higher in the prison context than in the general population [14]. There is a variation in the prevalence of hepatitis C in the prison environment. The present study identified reactive anti-HCV in 2.1% of respondents. National and international publications show variations in this prevalence for the prison population ranging from 0.2 to 15.1% [9, 15–17]. However, it is noteworthy that the presence of anti-HCV antibodies was 3.8 times higher than the estimated prevalence for the Brazilian population, which is 0.53%18. Even so, the Brazilian prison system has multiple structural limitations and lacks the conditions to carry out actions aimed at improving the prisoner's access to adequate health services [10].
As for demographic aspects, there is a similarity of the profile found in prison populations in other locations. A study carried out in Central Brazil with 3380 prisoners identified a mean age of 32 years, low educational level in 43% of men and 55% of women, and those living without a partner were 46% of men and 34% of women [17]. In Paraná, a recent publication showed that among 1132 incarcerated people, 48.6% were over 30 years old, 95.6% had low educational level and 53.4% lived without a partner [16].
As for sexual experiences, in Paraná, a study found that 91.3% of respondents reported heterosexuality as a sexual orientation; in addition to that, 84.8% had never had a sexually transmitted infection [16], results very similar to those described in the present study.
It is known that HCV transmission occurs mainly through contact with infected blood (through sharp objects), rather than through sexual contact [10]. However, other sexually transmitted infections can carry HCV. Since 2000, hepatitis C virus (HCV) has been an emerging epidemic among men who have sex with men (MSM) living with human immunodeficiency virus (HIV). HCV transmission in this population is associated with high-risk practices, such as unprotected traumatic sex, group sex and drug use [19].
The inconsistent use of condoms during sexual intercourse has been associated with HCV transmission in several studies, especially among men who have sex with men [20–22]. Unprotected sex can facilitate the transmission of sexually transmitted infections inside and outside the prison environment, especially if one takes into account the average number of 6.5 sexual partners that respondents reported in the year before prison. The low use of condoms during sexual relations was observed in the present study, both for those who receive intimate visits and for those who have sexual relations with fellow prisoners.
HIV/HCV co-infection is a reality to be faced, hence the importance of analyzing personal medical history. It is estimated that, worldwide, at least 2.3 million people are co-infected with HIV/HCV [3]. Co-infection with the B virus is not so commonly found [14, 23]. In the present study, 2.1% of the interviewees already knew they had HIV and 1.3% HBV. People who had a positive anti-HCV antibody already knew they had the hepatitis C virus (2.1%).
Regarding alcohol abuse, the number of respondents who consumed alcoholic beverages and the amount ingested per day was surprising, 188 grams of pure alcohol, equivalent to 4.7 times the safe amount for the non-development of alcoholic liver disease, for a man (40 grams). It is observed that the discussion of alcohol abuse and its relationship with exposure to HCV is not frequent, even though it is recognized that the drunk individual adopts higher risk behaviors [24] and evolves more frequently to liver cirrhosis and its complications [25].
Regarding drug use, a reality among the respondents was that they mentioned that non-injectable drug use was more frequent than injectable drugs. The use of marijuana and cocaine were more incidents, as described in Spain [26]. As for the consumption of cigarettes, it was frequent among 56.3% of the respondents, with an average consumption of 20.6 cigarettes a day, less than in a Spanish prison that found 76.1% of smokers [26].
Although the higher prevalence of anti-HCV can be attributed to conditions and experiences prior to incarceration, such as drug use and tattoos, stress within prisons, such as overcrowding and violence, can cause prisoners to initiate or continue unsafe activities [3].
Regarding other risk factors for exposure to HCV, it is known that several factors favor the spread of highly prevalent infections among prisoners. Sharing sharp objects, tattoo and piercing needles are practices associated with the spread of HCV within prisons [10]. Another aspect is related to the prison recidivism that occurred in 70.4% of the interviewees. This reality, also identified in the analysis of other prison communities, was still presented as a risk factor associated with positive anti-HCV serology [13].
4.1 Study limitations
One of the limitations of this study is that the sample was calculated for the population deprived of liberty in general, a study design with systematization of the sample is recommended. On the other hand, the acceptance of the study by the prisoners can be observed, since 240 people were tested, a greater number than expected by the sample calculation, and the participation was only interrupted due the COVID-19 pandemic.
Some aspects, within the application of the questionnaire, were not answered. However, these incomplete questionnaires were not disregarded, given the specificity of the study population, which is difficult to access. Furthermore, the study provided for the follow-up of patients reactive to anti-HCV, which, after the initial limitations imposed by the pandemic, began to be carried out. Information about risky behaviors such as sexual experiences and drug use was self-reported and may be prone to response bias and socially desirable responses.
Also, when addressing health in the prison system, one must reflect on masculinity. Dominant gender patterns can lead men to hide health issues [27].